Respiratory Therapy 101: Just Keep Breathing

In the course of doing my laundry today, I discovered that one of my new scrub tops has been covered in blood. I don’t know how I missed that yesterday or why nobody said to me “Hey dude your top’s covered in blood,” but I can only assume that it was busy and nobody really wanted to talk to blood-drenched guy.

I exaggerate, but the quantity is alarming. I suspect that it’s drippings from a lab draw I had to do yesterday in the ER…sometimes even when you pinch the tubing on the butterfly needle you can get a little leakage. Especially if you’re doing an arterial lab draw alone and you have to screw the damn syringes in by hand because using a Vacutainer on an artery is…well folks, it’s just not a good idea.

Anyway. I rubbed some stuff on the bloodstains and put it in the wash, and we’ll see how it comes out…but as the title says, if this top wasn’t a biohazard it would be a perfect costume for the evening’s festivities.

Happy Halloween, everybody. Remember: those razor blade stories are just urban legends designed by the media to propagate fear, so don’t waste the ER’s time by bringing in candy to be unless your jaw begins to bleed after you pop that tasty snickers. And to AJC up there in the Halloween Capitol Of The World, good luck with the weirdos tonight.

Some time ago I promised you new features: the hopeless case of the week and the success of the week. These features were part of an effort to create interesting content and explore some of the dichotomies of medicine. But me being me, I forgot all about them until today. Today, working in the ER, I got a new Hopeless Case Of The Week!

The hopeless case came in this morning via ambulance. I was sitting in our RT cave in the ER when my “spectralink” phone rang.

“Respiratory.” I drew a deep breath and sighed. In this ER, they either need me for something critical or something asinine. Middle ground is hard to come by.

A tinny voice leapt from the earpiece. “Intubated patient coming to Intensive One. Six minutes.”I got to my feet.

“Right!” Hanging the phone up, I grabbed my stethoscope and strode out into the ER, walking past The Hallway Patients and The Security Guards and eventually winding up in Intensive One. I turned on the ventilator and waited. Moments later EMS lurched into view, tugging a stretcher with a pile of blankets on it.

On closer inspection, the pile of blankets was a cachectic middle-aged individual. Their blue eyes were open and staring off into space; their wasted limbs were splayed lifelessly across the stretcher. The paramedic began to rattle off report: the patient was a middle-aged man from a local nursing home, with a history of IV drug use, drug-resistant pseudomonas, C-Diff, MRSA, various chronic failures, enormous amounts of thick yellow secretions indicating a fulminant pneumonia—and full-blown AIDS.

He had been found unresponsive in his room at the home, probably when the one aide for 100 patients poked him with a stick and he didn’t move. He had no DNR. He had no family. He was unable to decide for himself what to do…so now he sits in an ICU bed, intubated and ventilated, being pumped full of drugs while microorganisms eat him alive from the inside. His mere presence in the ICU puts healthcare workers of all stripes at risk. His quality of life is minimal. He is not aware of his surroundings, and he…is…going…to…die.

Despite all this, he sits in a 3,000-dollar-a-day plus intensive care bed. We are keeping his body alive as long as we possibly can, but for what? This case is 100% hopeless. If we cure him, he will return to the nursing home and then either die or come back to the ER again. If we don’t “cure” him but simply prolong his life for a long time, he will linger in our ICU, acquiring rare and exotic infections until the day that he dies in a high-risk ID-nightmare code blue.

I am at a loss to explain why we are doing this to this man. The compassionate thing to do would be to make him comfortable until his inevitable demise. But the promise of modern medicine is immortality at the expense of quality, and so…until he has the audacity to defeat our machinations, he will remain alive.

Ativan is one of my favorite drugs for patients to be taking. A wonderfully potent anxiolytic, it generally has a mellowing effect on jittery or nervous patients. Simply popping an Ativan pill or shooting someone up with the IV form of this drug can make interactions with anxious or agitated patients much, much better–unless it makes it worse*, but that’s a whole different post.

One area in which I feel Ativan is vastly underused is the respiratory care arena. Nebulized Ativan is something I have long advocated for, and it is an idea whose time has come. Here is why.

Nebulizer therapy is often ordered by caregivers for reasons that are not related to nebulizer therapy. Physicians have a habit of ordering nebulizers on patients for reasons that are unclear at best or outrageous at worst: for example, doctors who order Albuterol nebulizers on postoperative bunionectomy patients with no relevant history, or who order albuterol nebulizers to treat congestive heart failure.

Physicians are not the only guilty group. Nurses who hear “wet” lung sounds often insist that albuterol, a bronchodilator, will cure their patient of a non-bronchospastic condition such as pneumonia or CHF. Sometimes, nurses will insist that nebulizers be given to patients because “they have a history,” whether or not the patient is symptomatic at the present moment–this would be fine if they were asking us to deliver control medicine such as a long-acting beta agonist or an inhaled steroid, but almost always they are asking us to give rescue drugs that have no preventive effect to patients who are not in need of rescue. This drives me insane.

Nurses and physicians both often ask for nebulizer treatments simply because they have run out of other ideas and it makes them feel better. The psychological effect on the patient and the caregivers of “seeing” that something (such as a nebulizer) is being done is enormous, and I suspect that a great many nebulizers that are given in semi-emergent situations are given because people are out of ideas and want to feel that they are doing something concrete or visible.

Ativan nebulizers can solve all of these problems.

First, physicians who order nebulizers because they are out of ideas. Ativan has a broader spectrum of use than albuterol. Arguably, any patient who comes into the hospital could be given Ativan, since the experience of being hospitalized or treated as an outpatient is likely to generate anxiety. Now, physicians as a collective are not usually receptive to new ideas, so I have no hope of getting the ones who abuse nebulizers to stop doing so: but maybe I can make them do it in a way less harmful to the patient. If we could convince these nebulizer-loving MDs that Ativan–not Albuterol– was the new miracle drug, then we could successfully prevent patient anxiety and the anxiety of anybody within about two feet of the nebulizer.

As far as hypersensitive RNs** who believe that nebulizers will cure all of the ills of their patients from toe fungus to brain tumors, we can see once more the utility of Ativan nebulizers. By asking the nurse to administer the ativan nebulizer to the patient, we can be assured that simply due to the close proximity of the nurse to the anxiolytic mist, our “nuisance calls***” will drop by an enormous percentage–and that lucky patient will be able to relax and maybe even get some sleep in the bustling din of the hospital.

Finally we come to the nebulizers that are ordered just to make people feel better. Since this is the desire at the root of a large chunk of ordered nebulizers, putting Ativan into the neb cup and letting everyone inhale that delicious mist would actually meet the secret objective here. Physicians who just like to order nebs will actually feel better and maybe relax; nurses who want to feel like they are doing something more will be filled with sensations of joy and wonder; and patients will benefit enormously from the sudden drop in worries and the attention given to them by people hoping to get a little breath of fresh air out the end of the corrugated tubing.

Ativan nebs: their time has come.

*Ativan can cause confusion and delerium. Certain patients, especially in my experience elderly patients, will become confused and agitated by the administration of Ativan.

**Not all nurses fall into this category. I’ve been lucky enough to work with plenty of nurses who understand the relatively limited role of the nebulizer in patient care, but I have also been plagued by nurses who believe that Albuterol will raise the dead.

***A large percentage of the calls that I have personally gotten from floor nurses have been nothing more than nuisances. Many calls are genuine, but many more are simply because they believe that the Almighty Nebulizer Will Raise The Dead.

Can’t believe I forgot to link to Codeblog earlier.

Stay tuned to RT 101. Tomorrow: an epic argument in favor or ativan nebulizers!

It’s true. I like my patients to be well-sedated. There are some out there who think it’s cruel or unpleasant to sedate patients in the ICU environment, but speaking as someone who knows intimately the depths of the unpleasantness we can inflict on people in the drive to cure them, I think that sedation is a gift from above. Patients in the ICU are going through some of the most trying times of their lives: why wouldn’t we sedate them for it?

My favorite sedative agent would have to be the wonderful, beautiful and heavily-used drug Propofol. Terry at Counting Sheep has a wonderful post about this drug, which I urge you to go read immediately.

After working seven out of eight days in a row, I finally have a few days off in which to unwind. There’s an ice-cream social at the hospital to celebrate RT week, so the wife and I might pop in there and score us some free food.

Reading through the morning funnies today I came across this:

How true is this?

Wow. Apparently I’ve been doing something right, because the blog is approaching 25,000 hits on the ol’ hit counter. I guess I should be fair and remove about 5,000 hits from that for the random Googles (like ASS CPAP or HOW DO I EAT FENTANYL) that land people here by mistake. But 20,000 hits is nothing to sneeze at, so congratulations to me!

I’d offer a prize to visitor 25,000 but I don’t really have any prizes lying around and I’m too cheap to go buy one special. Maybe for the 100,000th hit, whenever that comes.

Uttered by a friend of mine:

“Sometimes I have to shut the office door at lunchtime because I swear like a longshoreman with terminal Tourettes.”

Best. Description. Ever.

As part of the ongoing Respiratory Care Week festivities at Sunny Flats Medical Center, the RT department has been having free lunches sponsored by various people who give us CEU-worthy lunchtime speeches. Even though today was my day off, I went in to hear the speech and get my CEU–and some freebies.

You see, the lunch today was sponsored by A Major Pharmaceutical Company. Major Pharmaceutical Company manufactures a specialty respiratory drug that is used with varying degrees of frequency here, and in an effort to boost the usage of their product they treated us RTs to a phenomenal lunch of delicious Italian foods, gourmet brownies and gallons of Sweet Tea. To further curry favor with us respiratory types,  the rep from MPC brought us toys.

I snagged myself a sweet stethoscope cover, a notebook, half a dozen pens for MPC’s various products, a magnet and a little hand-sanitizer bottle holder thing. The talk was by one of our intensivists, who was speaking about the need for better communication in the ICU to improve outcomes. He made some excellent points as far as I could tell, although I was somewhat distracted by my bag of goodies and my delicious foods.

I know there are ethical concerns about drug-company sponsored events, but frankly I like the freebies too much to be strongly opposed to drug rep lunches. Besides, it’s a free market: why shouldn’t companies be able to aggressively advertise?

More wacky medical tales to come soon.

From Jack Handey’s Deep Thoughts:

Broken promises don’t upset me. I just think, why did they believe me?

Today was a decent day at Sunny Flats. You may have noticed that I am working a lot; I am in fact doing a seven-of-eight stretch at the hospital in order to get some time off for personal reasons. Anyway, day six wasn’t all bad: no terminal extubations today, stable patients, a couple of post-thoracic-surgery recoveries to take care of and not many unexpected occurrences.

Since I’m too tired to make any real content, here are some observations from fellow blogger types. From Mielikki over at First, Do No Harm we have the tale of the week of DNR transfers to the ICU for questionable reasons. Evidently this streak of death and terminal weans isn’t limited to my work here at Sunny Flats.

Second, we have MonkeyGirl’s observations and thoughts about the “healthcare crisis.”  She makes the excellent point that even if we socialize medicine and make it “available” to everybody, the problems with resource allocation will occur since we aren’t treating the root of the problem: patients who abuse the system. We all know the types; the ER patients who use the ER for stupid things like pregnancy tests or narc abuse; the patients who, through astonishing apathy and/or phenomenal lack of self-care skills manage to get admitted every few weeks; and the people who improperly abuse government programs designed to help the truly needy. Probably the best solution to the problem is to simply allow hospitals to cut off problem people. I’m sure some people will whine about how we can’t turn people away, but I ask: why not? If they’re just wasting our time and money, why shouldn’t we be able to give them a swift kick in the ass? Hospitals are businesses, and no other business is forced to serve any idiot who demands services. A radical proposition, but we all know that radical propositions generate attention that may eventually lead to moderate solutions.

Also, it is Respiratory Care Week this week. So if you see any stray RTs out and about, wish them a happy RT week and they’ll be your friend forever.